BeneScope, Inc. Claims & Benefit Advocacy Services

As major changes are occurring in our nation's health care system, it becomes more and more evident that there are and will increasingly be significant gaps in the ability of a policy holder to successfully and expediently communicate with his/her insurance carrier concerning deductibles, unpaid claims, discrepancies in coverage and the many other problems and issues that require discussions and resolution.  Our BeneScope Claims & Benefit Advocacy service was founded to fill that communication gap by utilizing trained medical insurance liaisons who can build that bridge of information between the member and their insurer.  These subject matter experts take on the responsibility  of working with the member, speaking for the member, utilizing their industry knowledge and problem solving know- how, which then frees the member and their spouse to be focused on their work, their family and their lives.

Health insurance is extremely complex and has become even more complex as new federal laws and regulations take effect.  With the advent of the Affordable Care Act, and it's various components, many changes have and will continue to take effect that adds to the complexity.  One example of this is a new standardized billing code system that will add literally thousands of codes into the billing process.  The need to develop familiarity with these new codes will slow the claims process and, in some cases, cause claims to be denied on simple billing inconsistencies. This one element, alone,  will impact care providers, billing staff, policy holders, and even the insurance carriers themselves. 

Another key issue that will impact customer care over the coming months and potentially for years to come is the vastly expanded member volume, resulting from the Affordable Care Act providing opportunities for individuals previously uninsured.  This is a very important legislation and will assist many individuals and families but  will also expand the work load for billing and claims staff significantly.  It is also important to acknowledge staff reductions occurring and will continue to occur in carriers' customer service departments. This comes as a result of new regulations concerning the percentage of insurance company budget that can be dedicated to administrative services.   All of this is a recipe for customer care line back-ups and dropped calls.  Couple this with the confusion in new terminology and new requirements and the individual policy holder/member  will need to dedicate even more time and attention in order to solve his or her insurance problems. Often, the employee will go to their company's Human Resource Department for help which will add to that department's work load. As an employer, the demands on your employee's time and the frustration of the situation may end up being your problem as your production and perhaps even your company's safety record may suffer.

Below are just a few of the areas where  our BeneScope Claims & Benefit Advocacy expertise will work for you:

  • Unpaid or denied medical claims resulting from paperwork submission needs
  • Submission of corrected member insurance information
  • Coding and payment rules which may apply to the billing issue
  • Incorrectly applied deductibles
  • Condition specific or preventative care charges
  • Referral documentation
  • Benefit disputes arising from multiple policies/multiple carriers
  • Member's "out of pocket" responsibility
  • Clarifying provider network status confusions
  • Coordination of benefits between medical, dental, and other health service providers and insurers

Our Insurance liaisons know the  health care community as well as the insurance industry and this means that their interactions with both will be far more effective and timely.  We have all had the experience of calling a Customer Care Line only to find that they do not seem to be able to relate to the us culturally around health care because they are located thousands of miles away.  Couple this with off-shore outsourcing of these Customer Care positions, and you and the operator may both be struggling to understand each other which adds to the already intense frustration of the claims issue.